A Place All My Own Blackhawk

Based on document review and interview, the administrator failed to ensure that the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery per A.R.S. 36-420.01.A. Findings include: 1.A review of the facility policies and procedures, last updated on 2/26/2024, did not contain a training program which outlined the initial training and continued competency training in Fall Prevention and Fall Recovery per A.R.S. 36-420.01.A 2.A review of E1’s personnel record revealed a certificate for Fall Recovery training for 2024, however, there was no training for Fall Prevention per A.R.S. 36-420.01.A 3 . A review of E2’s personnel record revealed a certificate for Fall Recovery training for 2024, however, there was no training for Fall Prevention per A.R.S. 36-420.01.A. 4. A review of E3’s personnel record revealed a certificate for Fall Recovery training for 2024, however, there was no training for Fall Prevention per A.R.S. 36-420.01.A. 5. In an interview, E4 acknowledged that the administrator failed to ensure that the employees received training for Fall Prevention and Fall Recovery per A.R.S. 36-420.01.A.

Based on document review and interview, the administrator failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of the facility policies and procedures revealed no documentation showing a review or update of the policies and procedures. 2. In an interview, E4 acknowledged that the policies and procedures have not been reviewed and signed off, every three years.

Based on record review and interview, the administrator failed to ensure that at the time of admission, a resident or the resident's representative received a written copy of the resident rights. Findings include: 1 . A review of R1's and R2's medical records revealed no document signed by the resident or the resident's representative regarding Resident Rights. 2 . In an interview, E4 acknowledged that there was not a signed copy of the resident's rights in R1's or R2's files.

Based on record review and interview, the administrator failed to ensure that at the time of admission, a resident or the resident's representative received a written copy of the resident's rights. Findings include: 1. A review of R1's and R2's records revealed no written copy of the resident's rights signed by the resident or resident's representative. 2. In an interview, E4 acknowledged that there was not a signed Resident's Rights document in R1's and R2's records.

Based on document review and interview, the administrator failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documents revealed no documentation that disaster drills were completed for employees on each shift at least once every three months. 2. In an interview, E4 acknowledged that a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on document review and interview, the administrator failed to ensure that an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documents revealed no documentation that evacuation drills were completed for employees on each shift at least once every three months. 2. In an interview, E4 acknowledged that an evacuation drill for employees was not conducted on each shift at least once every three months and documented.